Preoperative Vascular Imaging in Lower Extremity Free Flap Reconstruction: Comparison Between Imaging Modalities.

BACKGROUND: Adequate vascular anatomy and perfusion status are essential for successful lower extremity free tissue transfer. Computed tomography angiography (CTA) is widely available, minimally invasive, and enables visualization of soft tissues and bones. Angiography permits temporal evaluation of flow, identifies potential needs for concurrent endovascular interventions, and enhances visibility in the setting of hardware. Despite widespread availability of these imaging modalities, no standardized algorithm for preoperative imaging prior to lower extremity free flap reconstruction exists. METHODS: Current Procedural Terminology (CPT) codes identified patients undergoing free flap reconstruction of the lower extremity over an 18-year period (2002-2020). Electronic medical records were reviewed for patient, treatment, and imaging characteristics, and pre- and post-imaging laboratory values. Outcomes included imaging findings and related complications and surgical outcomes. RESULTS: In total, 405 patients were identified, with 59% (n = 238) undergoing preoperative imaging with angiography, 10% (n = 42) with CTA, 7.2% (n = 29) with both imaging modalities, and 24% (n = 96) with neither performed. Forty percent (122 of 309) of patients who underwent preoperative imaging had less than 3-vessel runoff. Four patients developed contrast-induced nephropathy (CIN) after angiography only and one after having both CTA and angiography. Vessel runoff on CTA and angiography demonstrated moderate correlation. CONCLUSION: Most patients undergoing lower extremity free tissue transfer underwent preoperative imaging with angiography and/or CTA, 40% of which had less than 3-vessel runoff. Both angiography and CTA had low complication rates, with no statistically significant risk factors identified. Specifically, the incidence of CIN was not found to be significant using either modality. We discuss our institutional algorithm to aid in decision-making for preoperative imaging prior to lower extremity free flap reconstruction. Specifically, we recommend angiography for patients with peripheral vascular disease, internal hardware, or distal defects secondary to trauma.

Analysis of Complications in Patients With a History of Cannabis Use and Tobacco Use Undergoing Implant-Based Breast Reconstruction.

BACKGROUND: There is limited information regarding the perioperative effects of marijuana in breast reconstructive surgeries. OBJECTIVES: The objective of this study was to explore the association between a history of cannabis use and postoperative complications in the setting of implant-based breast reconstruction. METHODS: Two databases, TriNetX and PearlDiver, were queried for patients undergoing implant-based breast reconstruction. Patients were divided into 4 groups based on active ICD-10 diagnostic codes: (1) cannabis use only, (2) tobacco use only, (3) cannabis and tobacco use, and (4) neither cannabis nor tobacco use. Associations with postoperative complications were analyzed with a logistic regression test. RESULTS: TriNetX search revealed that 327 patients had an active diagnosis of cannabis use only and 1118 had an active diagnosis of tobacco use only. Patients in the cannabis only cohort had a significantly increased risk of developing surgical site infection. Patients in the tobacco only cohort had significantly increased risk of developing wound dehiscence, need for debridement, and surgical site infection. The PearlDiver search included 472 patients who had an active diagnosis of both cannabis and tobacco use and 17,361 patients with a diagnosis of tobacco use only. Patients with a diagnosis of cannabis and tobacco use had a significantly increased risk of developing postoperative complications including surgical site infection, wound dehiscence, need for incision and drainage, and debridement. CONCLUSIONS: Patients undergoing implant-based breast reconstruction with an active diagnosis of cannabis with or without tobacco use were at increased risk of developing postoperative complications, and the risk was even higher in patients using both tobacco and cannabis.

Outcomes following replantation surgery.

The ability to perform surgical replantation of individual digits and limbs can provide substantial functional improvement for patients who sustain devastating upper extremity injuries. Defining success in replantation surgery extends beyond the acute period and the binary metrics of survival or loss of the replanted part to include the long-term overall functional outcomes. Functional outcomes include both objective clinical evaluation and patient-reported outcomes. There has been significant variation in the way outcomes following replantation are measured, which inherently leads to heterogeneity in the reported outcome data. Given the variability among outcome measures, we aim to explore the outcomes of replantation surgery, particularly clinical evaluation and patient-reported functional outcomes following replantation.

Management of isolated volar lunate facet fractures of the distal radius.

Distal radius fractures are among the most common fractures treated globally. Consideration of the mechanism of injury and careful radiographic assessment contributes to appropriate management of these injuries in isolation or jointly with other fractures or injuries affecting the wrist joint. Treatment options can range from non-operative management to a variety of fixation techniques. Interest in the distal radius fractures was renewed as open reduction and monoblock volar locking plate fixation became the preferred contemporary treatment in the last few decades. Isolated volar lunate facet (VLF) fractures are uncommon. However, the stability of the entire carpus may be compromised with fractures of the volar marginal rim. Inadequately or improperly treated fractures of the VLF can lead to significant long-term complications. A critical approach to this unique fracture pattern's evaluation, management, and surgical fixation is paramount for successful and reproducible outcomes in stability and durability.

Acute Compression of the Anterior Interosseous Nerve After a Proximal Both-Bone Forearm Fracture: A Case Report.

Anterior interosseous nerve (AIN) syndrome is a rare condition characterized by isolated weakness in the flexor pollicis longus (FPL) muscle, sometimes accompanied by weakness in the index flexor digitorum profundus (FDP) muscle. In this clinical case report, an 18-year-old male presented with a right proximal both-bone forearm fracture that was sustained while playing soccer, with subsequent development of AIN palsy, without sensory deficits or progressive pain. Preoperative imaging was performed, showing a proximal third radius and mid-shaft ulna fracture. Given the progressive presentation of an acute AIN palsy, the patient was indicated for urgent operative intervention. During exploration and decompression of the AIN within the pronator tunnel, the nerve was found to be in continuity but was compressed by a large hematoma and the distal radial shaft. The patient recovered full median nerve function by his six-week postoperative examination and by his final follow-up recovered full range of motion with painless return to full activities. In proximal or mid-shaft both-bone forearm fractures, a careful neurovascular exam is essential, as uncommon conditions like anterior interosseous syndrome (AIS) can present without obvious sensory deficits or pain. Potential etiology for traumatic AIN compression includes significant fracture displacement, soft tissue injury, active extravasation on advanced imaging, and/or clinical concern for compressive hematoma. Patients presenting with FPL and/or index FDP weakness in the absence of sensory deficits or pain on passive stretch may benefit from dedicated surgical exploration and decompression of the AIN to prevent irreversible nerve damage.

Overview and management of complications after digital replantations.

The main complications after digital replantation are discussed in this review article. These complications include vascular compromise, infection, partial necrosis, delayed union or nonunion, atrophy and so on. The countermeasures for these complications are reviewed and the authors' methods are also introduced and discussed.

Ulnar Nerve Compression at the Elbow Secondary to Intramuscular Lipoma of the Flexor Carpi Ulnaris: A Case Report.

CASE: A 62-year-old right-hand-dominant woman presented with 1 year of persistent radiating pain, weakness, and paresthesias in her left forearm and hand. Electromyography findings were significant for ulnar neuropathy distal to the branch innervating the flexor carpi ulnaris (FCU), without superimposed cervical radiculopathy or other focal entrapment neuropathy. During open ulnar nerve neurolysis, an intramuscular lipoma was encountered within the FCU. Lipoma excision and cubital tunnel release with ulnar nerve transposition were performed with complete relief of neuropraxia. CONCLUSION: We demonstrate full neurologic recovery after intramuscular lipoma excision and cubital tunnel release. Although rare, anomalous anatomy and tissue overgrowth should remain on the differential for patients presenting with atypical neuropraxia.

A Rare Case of Traumatic Acute Pronator Syndrome in the Setting of Anticoagulation Therapy.

Pronator syndrome (PS) is a rare type of peripheral compression neuropathy in which the median nerve becomes entrapped as it passes through the pronator teres muscle at the proximal forearm. We report an unusual case of acute PS in a 78-year-old patient on warfarin who presented after traumatic forearm injury with forearm swelling, pain, and paresthesias. After emergent nerve decompression and hematoma evacuation, the patient regained near complete recovery of median nerve function six months after diagnosis and treatment.

Plastic Surgery Training: Trends in Hand Surgery Fellowship in the Setting of a Pandemic.

Given the diminishing presence of hand surgeons trained in plastic surgery, we evaluated the associated trends in annual hand meeting educational content and postgraduate job offerings, and analyzed the effect of the coronavirus disease 2019 (COVID-19) pandemic on trainees in hand surgery. Methods: Hand meeting registration and educational content were analyzed over the past 10 years. Current hand surgery job offerings were evaluated for training requirements, and the annual rates of subspecialty certificate in surgery of the hand board certifications were compared across training backgrounds. Results: Top categories of annual meeting educational content were "bone/joint," "other," and "professional development." A majority of American Society for Surgery of the Hand presidents had training backgrounds in orthopedics (55%), followed by plastics (23%) and general surgery (22%). The job offerings on the American Society for Surgery of the Hand and Association for Surgery of the Hand websites specified more training requirements in orthopedics than in plastics. Additionally, there were two to three times as many examinees taking the surgery of the hand examination from orthopedic surgery compared with plastics, with an overall higher pass rate. Hand fellowship programs were also predominantly offered for orthopedic surgery (80.8%). Conclusions: Optimization of training, society membership, and clinical practice profiles may increase the presence of plastic surgery-trained hand surgeons. The extent of the economic impact of the COVID-19 pandemic is yet to be fully determined, but our analysis suggests that a lucrative market for reconstructive/hand surgery may exist in the face of economic downturn.

Analysis of Postoperative Distal Radius Fracture Outcomes in the Setting of Osteopenia and Osteoporosis for Patients with Comorbid Conditions.

Purpose: Distal radius fractures (DRFs) are among the most common orthopedic injuries, especially in the elderly. A wide variety of approaches have been advocated as successful treatment modalities; yet, there remains variability in practice patterns of DRF in patients with osteoporosis and osteopenia. Using large data set analysis, we sought to determine the risk profile of operative fixation of DRF in patients with low bone mineral density. Methods: A commercially available health care database, PearlDiver, was queried for all patients who underwent open reduction internal fixation of DRFs between 2010 and 2020. The study population was divided into groups based on the presence or absence of osteopenia or osteoporosis and was further classified by patients who were receiving bisphosphonate therapy. Complication rates were calculated, including rates of malunion, surgical site infection, osteomyelitis, hardware failure, and hardware removal. Five-year future fragility fractures were defined in hip, vertebrae, humerus, and wrist fractures. Chi-square analysis and logistic regression were performed to determine an association between these comorbidities and various postoperative complications. Results: A total of 152,926 patients underwent open reduction internal fixation of a DRF during the study period. Chi-square analysis of major complications at 3 months showed a statistically significant increase in malunion in patients with osteopenia (P = .05) and patients with osteoporosis (P = .05) who underwent open reduction internal fixation. Logistic regression analysis at 12 months after surgery demonstrated that osteopenia was associated with an increased risk of hardware failure (P < .0001), hardware removal (P < .0001), surgical site infection (P < .0001), and malunion (P = .004). Osteoporosis was associated with a significantly increased risk of hardware failure (P = .01), surgical site infection (P < .0001), and malunion (P < .0001). Conclusions: We demonstrated, using large data set analysis, that DRF patients with osteopenia and osteoporosis are predicted to be at increased risk of multiple postoperative complications, and thus, bone density should be strongly considered in treatment planning for these patients. Type of study/level of evidence: Prognostic III.

Venous Thromboembolism after Deep Inferior Epigastric Perforator Flap Breast Reconstruction: Review of Outcomes After a Postoperative Prophylaxis Protocol.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flap breast reconstruction is among the higher-risk patient groups for venous thromboembolism (VTE) in plastic surgery. Surgeons often opt for a patient-specific approach to postoperative anticoagulation, and the field has yet to come to a consensus on VTE chemoprophylaxis regimens. METHODS: A new chemoprophylaxis protocol was introduced starting March 2019 that involved two weeks of treatment with enoxaparin, regardless of patient risk factors. A retrospective chart review was conducted on all patients who underwent DIEP flap breast reconstruction at our institution between January 2014 and March 2020. Patients were grouped based on whether they enrolled in the new VTE protocol in the postoperative period or not. Patient demographics, prophylaxis type, and outcomes data were recorded, retrospectively. The primary outcome measure was postoperative VTE incidence. RESULTS: Risk of VTE was significantly higher in patients discharged without VTE prophylaxis compared to patients discharged with prophylaxis (3.7% vs. 0%, p = 0.03). Notably, zero patients in the VTE prophylaxis group developed a DVT or PE. Additionally, the risk of a VTE event was 25 times greater in patients with a Caprini score greater than or equal to 6 (p=0.0002). CONCLUSIONS: We demonstrate the successful implementation of a two-week VTE chemoprophylaxis protocol in DIEP flap breast reconstruction patients that significantly reduces the rate of VTE while not affecting the rate of hematoma complications.

Breast Reconstruction Trends in the Setting of Postmastectomy Radiation Therapy: Analysis of Practices among Plastic Surgeons in the United States.

Radiation is an integral part of breast cancer therapy. The ideal type and timing of breast reconstruction with relation to radiation delivery are not well established. The study aimed to identify reconstructive practices among American plastic surgeons in the setting of pre- and postmastectomy radiation. Methods: A cross-sectional survey of members of the American Society of Plastic Surgery was performed. Practice/demographic information and breast reconstruction protocols were queried. Univariate descriptive statistics were calculated, and outcomes were compared across cohorts with χ2 and Fischer exact tests. Results: Overall, 477 plastic surgeons averaging 16.3 years in practice were surveyed. With respect to types of reconstruction, all options were well represented, although nearly 60% preferred autologous reconstruction with prior radiation and 55% preferred tissue expansion followed by implant/autologous reconstruction in the setting of unknown postoperative radiation. There was little consensus on the optimal timing of reconstruction in the setting of possible postoperative radiation. Most respondents wait 4-6 or 7-12 months between the end of radiation and stage 2 implant-based or autologous reconstruction. Common concerns regarding the effect of radiation on reconstructive outcomes included mastectomy flap necrosis, wound dehiscence, capsular contracture, tissue fibrosis, and donor vessel complications. Conclusions: Despite considerable research, there is little consensus on the ideal type and timing of reconstruction in the setting of pre- and postoperative radiation. Understanding how the current body of knowledge is translated into clinical practice by different populations of surgeons allows us to forge a path forward toward more robust, evidence-based guidelines for patient care.

Multidisciplinary Treatment of Persistent Nontuberculous Mycobacterial Spinal Hardware Infection with a Pedicled Superior Gluteal Artery Perforator Flap.

Nontuberculous mycobacterial hardware infections are extremely challenging to treat. Multidisciplinary care involving removal of infected hardware, thorough debridement, and durable soft tissue coverage in conjunction with antibiotic therapy is essential for successful management. This case report presents a patient with chronic mycobacterial spinal hardware infection that underwent successful treatment with aggressive serial debridements and reconstruction with a large pedicled superior gluteal artery perforator flap coverage.